1 Medical-Surgical Nursing: Concepts & Practice3rd edition Chapter 28 Care of Patients with Disorders of the Upper Gastrointestinal System Copyright © 2017, Elsevier Inc. All rights reserved.
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4 Theory Objectives Discuss eating disorders and their management, including bariatric surgery. Compare the signs and symptoms of oral, esophageal, and stomach cancer. Illustrate the cause of gastroesophageal reflux disease (GERD). Explain the etiology and prognosis for Barrett’s esophagus. Describe the pathophysiology, means of medical diagnosis, and treatment for gastritis.
5 Theory Objectives (Cont.)Compare and contrast the treatment and nursing care of the patient with GERD and a patient with peptic ulcer. Review the difference in the care of the patient with a nasogastric tube for decompression and care of the patient with a feeding tube. Compare the care for a patient receiving total parenteral nutrition with care of the patient receiving enteral feedings.
6 Clinical Practice ObjectivesImplement a teaching plan for a patient who has GERD. Plan postoperative care for a patient having gastric surgery. Demonstrate proper care of the patient with a Salem sump tube for gastric decompression.
7 Clinical Practice Objectives (Cont.)Manage a tube feeding for the patient receiving formula via a feeding pump. Review a nursing care plan for the patient with a gastrointestinal disorder. Write a nursing care plan for the patient with an upper gastrointestinal disorder.
8 Anorexia Nervosa – Psych DisorderPatients with anorexia nervosa refuse to eat adequate quantities of food and are in danger of literally starving to death. Diagnosis requires extensive interviewing and treatment, including behavior modification and nutrition support, which may take months to years.
9 Bulimia Nervosa Patients with bulimia consume large quantities of food and then induce vomiting to get rid of it so that weight is not gained. Laxatives – purge after the eating binge Some patients with anorexia nervosa also have bulimia. Some individuals practice bulimia occasionally without harm.
10 Bulimia Nervosa (Cont.)Bulimia can lead to severe fluid and electrolyte imbalances, dental problems, starvation, and death. Treatment of bulimia includes psychotherapy, antidepressant medication, and behavior modification.
11 Obesity Etiology and pathophysiology – diet, lack of exercise and overconsumption of food Signs and symptoms – obsese 20% over ideal weight Diagnosis Height and weight chart Waist and hip circumference Body mass index (BMI)
12 Older Adult - Obesity Decreased mobility from arthritisSnacking on junk foods to replace meals Metabolic rate slows – need less calories than before
13 Obesity Treatment Bariatric surgery – reduces gastric capacityExtensive counseling and assessment Modify lifestyle and stringent regimen required to lose weight and keep weight off Types – see page 646 Gastric restrictive Malabsorptive Gastric restrictive combined with malabsorptive surgery
14 Bariatric Surgery Preoperative careThere is greater risk of pulmonary embolism and thrombus formation, as well as death, for obese patients.
15 Restrictive ProceduresLaparoscopic adjustable gastric banding is performed by placing an inflatable band around the fundus of the stomach. The band is inflated and deflated via a subcutaneous port to change the size of the stomach as the patient loses weight.
16 Restrictive Procedures (Cont.)For vertical banded gastroplasty, the surgeon creates a small stomach pouch by placing a vertical line of staples. A band is placed to provide an outlet to the small intestine.
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18 Malabsorptive and Combination ProceduresThe total gastric bypass procedure causes severe nutritional deficiencies and is no longer recommended. The roux-en-Y gastric bypass (RYGB) limits the stomach size, and the duodenum and part of the jejunum are bypassed. This limits the absorption of calories.
19 Complications Leakage of stomach contents Gastric stretchingDumping syndrome – nausea, weakness, sweating, and diarrhea that occurs after meals Nutritional deficiencies—iron, vitamin B12, calcium, and folate Approx 1/3 of the bariatric patients develop gallstones because of the rapid weight loss With the RYGB procedure, there is danger of leakage of stomach contents into the abdomen in the early postoperative period. Later, gastric stretching may cause the staple line to break and a leak to occur. Signs and symptoms are tachycardia, dyspnea, or restlessness. An upper gastrointestinal (GI) series or computed tomography scan can diagnose the problem. The band in the vertical banding procedure may erode into the stomach over time and cause leakage. RYGB patients are also at risk for dumping syndrome, which results in nausea, weakness, sweating, and diarrhea. These symptoms tend to occur after meals that include concentrated sweets; therefore, RYGB patients should be advised to avoid refined sugars. Other complications of major surgery may occur in the respiratory and cardiovascular systems. About a third of patients who undergo bariatric surgery develop gallstones. Ursodeoxycholic acid therapy can be used to treat the gallstones, although poor compliance and cost are issues for this therapy (Patel et al., 2009). All bariatric surgery patients are at risk of nutritional deficiencies. Those with the RYGB procedure are most likely to develop deficiencies of iron, vitamin B12, calcium, and folate. Supplements must be taken for life.
20 Healthy People 2020 Goals Related to Losing Weight and ObesityIncrease the proportion of adults who are at a healthy weight. Reduce the proportion of adults who are obese. Reduce the proportion of children and adolescents who are overweight or obese.
21 Assessment Family history Contributing factorsRecord of eating patterns for a 7-day period Weight and height BMI Skinfold thickness measurement General health assessment
22 Expected Outcomes Patient will make positive statements about decreasing body size. Patient will verbalize feelings of self-worth.
23 Implementation Diet and exercise plan Lifestyle and preferencesEating and exercise diary Guidance and support Discourage fad diets and emphasize the importance of a well-balanced, nutritious, low-calorie diet. Commercial programs on weight reduction
24 Upper GI Disorders Stomatitis – inflammation of the mucous membranes of the mouth Causes – smoking, excessive alcohol, pathogenic organisms, radiation therapy and drugs (chemotherapy) Dysphagia – difficulty swallowing Causes –inflammation, tumors, neurologic Dos, stroke Diagnosis – eval by speech therapist Treatment – select foods, liquids (thickened) Nursing management – have patient “practice swallowing” prior to eating meals
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26 Cancer of the Oral CavityEtiology – unknown cause, smoking, alcohol Pathophysiology – Leukoplakia (usually seen by a dentist) lesion on tongue or mucosa Signs and symptoms – sores on lips/in mouth that don’t heal in 2 weeks Diagnosis—physical examination and biopsy Treatment—radiation, chemotherapy, and surgery Nursing management – monitor airway, tube feedings
27 Cancer of the EsophagusCigarette smoking is a major cause of esophageal cancer in the United States. When combined with heavy alcohol consumption, the risk for esophageal cancer greatly increases. Esophageal cancer is the second most common cancer in China but is seen less in North America. Both substances are irritants to the mucosa of the esophagus. Cigarettes and smokeless tobacco are responsible for 14,530 deaths from esophageal cancer annually (American Cancer Society, 2009).
28 Cancer of the Esophagus (Cont.)GERD is a cause of Barrett’s esophagus, which is a precancerous condition.
29 Barretts esophagus
30 Cancer of the Esophagus (Cont.)Signs, symptoms, and diagnosis – dysphagia, hoarseness, persistent cough Treatment Esophagectomy – removal of sections of the esophagus then reconstructed with stomach parts Nursing management Postoperative care – maintain patent airway- Nutrition – parental fluids initially, gradually bland foods, small, frequent meals
31 Audience Response Question 1When screening for the presence of risk factors for oral and pharyngeal cancers, the nurse would ask which question(s)? (Select all that apply.) “How much alcohol do you consume?” “Have you had any oral lesions?” “Do you have family members who have cancer?” “What do you smoke?” “Have you been exposed to hepatitis virus?” Correct Answer: 1, 2, 3, and 4
32 Hiatal Hernia (Diaphragmatic Hernia)Etiology and pathophysiology- defect in the wall of the diaphragm where the esophagus passes through. Protrusion of part of the stomach or lower part of the esophagus up into the thoracic cavity. Signs and symptoms – none there may be reflux of stomach acid, feeling of pressure after eating from reflux, worse when lying down.
33 Treatment of Hiatal HerniaReduce weight. Avoid tight-fitting clothes around the abdomen. Take antacids and histamine (H2)-receptor antagonists. Elevate head of the bed on 6- to 8-inch blocks. Take proton pump inhibitors (PPIs).
34 Treatment of Hiatal Hernia (Cont.)Instruct not to eat within several hours before going to bed. Limit intake of alcohol, chocolate, caffeine, and fatty foods. Avoid smoking.
35 Nursing Management Teach ways to prevent pain and reflux.Encourage weight reduction. Remind the patient to stay upright for 2 hours after eating and not to eat for 3 hours before bedtime.
36 Gastroesophageal Reflux DiseaseEtiology and pathophysiology – transient relaxation of the lower esophageal sphincter – may accompany hiatal hernia Signs and symptoms – heartburn (dyspepsia) reflux, dysphagia Diagnosis and treatment Nursing management Diet therapy, lifestyle changes, drug therapy, and education Complications
38 Gastroenteritis Caused by food or water contaminated with a virus, a pathogenic bacteria, or parasites Signs and symptoms – vomiting, elevated WBCs, abdominal cramping, diarrhea, blood or mucus in stool Management – NPO until vomiting stops, then fluids with glucose and electrolytes, after 24 to 48 hrs, medication may be given if vomting/diarrhea continues
39 Gastritis Etiology –Helicobacter pylori bacteria (could also be viruses or other bacteria) Pathophysiology – acute or chronic inflammation of the lining of the stomach Signs and symptoms – anorexia, nausea, vomiting, pain and tenderness in stomach Diagnosis – hx, physical exam & endoscopy Treatment – Antispasmodics, antacids, H2 receptor antagonist, proton pump inhibitor to decrease hydrochloric acid
40 Treatment for GastritisAcute versus chronic gastritis Chronic gastritis Antispasmodics Antacids H2-receptor antagonist such as ranitidine PPIs Antibiotic therapy for Helicobacter pylori
41 Peptic Ulcers – loss of tissue of the upper GI tractEtiology H. pylori is the major cause – smoking and NSAID use are other causes Duodenal ulcers and some pre-pyloric ulcers Gastric ulcers Tension, anxiety, and prolonged stress does have impact of the progression of ulcers Drug-induced ulcers Stress ulcers – different from peptic ulcer –more acute and more likely to produce hemorrhage- hazard for patients in ICU for extensive periods
42 Peptic Ulcers (Cont.) Pathophysiology – mucosa cannot protect itself from corrosive substances. Signs and symptoms Daily pattern of pain Gastrointestinal bleeding – c/o weakness, feeling faint, N&V, restlessness, thirst, confusion. Vomit bright red blood, or coffee ground look (blood with gastric juices) or appears in stool. Diagnosis Endoscopy Gastric acid analysis
43 Peptic Ulcers (Cont.) page 655The most common site is the duodenum just beyond the pyloric muscle See Figure 28-3 on p A, Gastric. B, Duodenal.
44 Treatment Antacids Gastric bleeding and normal saline lavageH2-receptor antagonist PPIs Presence of H. pylori—administration of clarithromycin (Biaxin) plus another antibiotic, an H2 inhibitor, and a PPI
45 Safety Alert page 656 PPI drug interactionsPPI slow liver’s ability to metabolize and clear drugs from the bloodstream CAUTION with patients taking Valium, Dilantin, and Coumadin. Watch for signs of toxicity
46 Peptic ulcer
47 Nursing Management ComplicationsHemorrhage – the ulcer erodes vessels, causing bleeding into the stomach Perforation –sudden/severe pain upper abdomen erosion of ulcer through the walls of stomach/intestine into the peritoneal cavity spilling contents of the GI tract Obstruction – persistent vomiting from scarring at the pylorus –narrow the stomach outlet
48 Surgical Treatment of Peptic Ulcer- page 657Pyloroplasty with truncal or proximal gastric vagotomy (severe 10 cranial nerve that stimulates acid secretion) – widen the pylorus Subtotal gastrectomy (gastric resection) Total gastrectomy – total removal of stomach. Esophagus is joined to the small intestine
49 Nursing Care of the Patient Undergoing Gastric SurgeryPreoperative care – liquid diet, day of surgery NPO, NG tube all stomach contents suctioned out in OR Postoperative care – gradual addition of food Specific patient teaching Diet restrictions Dumping syndrome
50 Dumping syndrome
51 Gastric Cancer Etiology acholorhydria (absence of hydrochloric acid) pernicious anemia, diet high in nitrates, H.pylori, genetics, type A blood type Signs and symptoms – no symptoms until far advanced, indigestion, loss of appetite, N&V Pathophysiology - tumors arise in pyloric area. Spreads to layers of stomach, lymph nodes, the liver and ovaries in women
52 Gastric Cancer Diagnosis –upper GI series, endoscopy with biopsyTreatment – removal of tumors, lymph node dissection, radiation/chemo
53 Common Therapies for Disorders of the Gastrointestinal SystemGastrointestinal decompression – abdominal distention from excess fluids and gases. Insertion of NG tube used to remove. If using Salem Sump Tube – keep the tube above the level of the stomach Enteral nutrition –small bore tube inserted confirmed placement with xray before feedings start Total parenteral nutrition – IV feeding using a large central line such as superior vena cava
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55 Small-Bore Feeding Tube PlacementSee Figure 28-5 on p. 663.
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